Passed in 2010, the Patient Protection and Affordable Care Act, referred to as the ACA, is a healthcare reform law that aims to make health insurance attainable and affordable to more Americans.
In fact, since its inception, the ACA – nicknamed Obamacare – has provided access to healthcare to 20 million Americans.
Is there an ACA health insurance plan that fits your needs?
Everything you need to know about securing affordable healthcare is found here. Consider this your comprehensive guide to understanding the basics of the Affordable Care Act, discovering plans available to you, and the purchasing process.
Table Of Contents
Overview of the Affordable Care Act
There are six fundamental questions about the ACA that need to be answered before moving forward.
What is the ACA?
Passed at the federal level, which means the law applies to the entire United States, the Affordable Care Act expanded access to cost-effective health insurance to tens of millions of Americans.
The act’s provisions have been adjusted and updated since initially passed under President Obama’s administration.
At present, key details to the ACA include:
- The health insurance Marketplace, also known as an exchange, is the location to purchase coverage.
- Individuals with preexisting conditions cannot be denied or charged more for coverage.
- Children can remain on their parent’s insurance plan until age 26.
- Preventative care is included at no additional cost.
- Subsidies or tax credits are available on the Marketplace to qualifying individuals and families.
Note – the individual mandate penalty, which was initially part of the ACA law and fined those without adequate healthcare coverage, was repealed in 2019. However, in 2022, certain states implemented their own specific mandates and penalties.
There are 10 fundamental aspects of healthcare coverage required under the ACA:
- Ambulatory patient services – outpatient care without hospital admittance.
- Preventative wellness services – including chronic disease management.
- Hospitalization – such as overnight stays and surgery.
- Pregnancy, maternity and newborn care – before and after birth.
- Prescription drugs – including brand name and specialty pharmaceuticals.
- Emergency services – such as visits to the emergency room.
- Laboratory services – including services to diagnose and screen patients.
- Mental health, substance use disorder – includes behavioral health treatment, such as counseling and psychotherapy.
- Rehabilitative and habilitative services – services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.
- Pediatric services – this includes oral and vision care, but does not include adult dental and vision coverage.
Note – The ACA also includes access to breastfeeding equipment and support, birth control, and counseling.
Important – Consider a separate dental, vision, and hearing policy for comprehensive coverage.
Additionally, there are legal rights ACA policyowners should be aware of:
- You have the right to appeal an insurer’s decision to not pay a claim.
- If an insurer ends coverage, they are required to provide an explanation.
- Employees have protection from employer retaliation based on receiving a premium tax credit or reporting violations of the ACA to their employer or government..
Who Can Buy An ACA Plan?
Most Americans qualify.
In fact, there are just a small number of instances in which someone cannot buy a plan through the Affordable Care Act.
You cannot buy a plan under the following circumstances:
- Not a U.S. citizen.
- Not living in the United States.
- Are incarcerated.
- Have Medicare coverage.
If none of the above circumstances apply to you, an ACA plan is available for purchase.
How Do I Buy An ACA Plan?
The ACA law introduced the Marketplace, also known as the exchange, as a place for Americans to purchase health insurance.
Your resident state determines the specific path for purchasing healthcare coverage.
At the federal level, Healthcare.gov provides an exchange for you to shop, compare, and buy coverage.
You need to know, however, that specific states do not sell plans at the federal level, and instead, offer healthcare plans through state-run exchanges.
Eighteen states provide their own exchange, or Marketplace:
- District of Columbia
- New Jersey
- New Mexico
- New York
- Rhode Island
When Can I Buy An ACA Plan?
Americans purchase an Affordable Care Act health insurance plan during the Open Enrollment Period (OEP), which occurs yearly from November 1 to January 15 (in most states).
Typically, this is the only timeframe in which a change can be made to your health insurance.
There are specific circumstances that will allow someone to enroll in a healthcare plan outside of the OEP. Called a Special Enrollment Period (SEP), the following events are considered acceptable reasons, or qualifying life events:
- Job loss
- Marriage or divorce
- Loss of coverage
- Moving to a new zip code
- New child or death in the family
- Change in citizenship
- Change in subsidy eligibility
- Government error
- Qualifying federal reason
Note – you have 60 days before and after the life event to enroll into – or make a change to – an ACA plan.
How Much Will An ACA Plan Cost?
Health insurance plans through the Affordable Care Act are typically cost-effective. In fact, in a rare turn of events, many may have seen lower premiums recently, or can expect them in the near future.
The American Rescue Plan Act of 2021 promoted health insurance savings by:
- Increasing the number of individuals eligible for help paying for health coverage.
- Marketplace enrollees likely qualify for additional tax credits.
Further, the Inflation Reduction Act extends healthcare tax credits that were set to expire and continues to lower ACA health insurance premiums.
The Inflation Reduction Act keeps these savings and lower costs through 2025.Healthcare.gov
Just how affordable are the plans? It depends on your specific circumstances, but for reference, four out of five Americans were able to find a plan for $10 or less per month.
There are a number of factors that influence the cost of your ACA health insurance plan:
- Health insurance carrier
- The state you live in
- Type of plan you select
- Whether you qualify for tax credits and subsidies
Do I Have ACA Plan Choices?
The Affordable Care Act organizes their health plans into four primary categories: Bronze, Silver, Gold and Platinum.
The best plan for you depends on your needs, budget and health.
The most affordable plan offered.
Key features of the ACA Bronze plan include:
- Lowest monthly premiums
- Highest costs when care is required
- Deductibles may cost up to thousands of dollars yearly
- Insurance carrier pays 60% and you pay 40%
Bottom line – the Bronze plan is best for someone wanting a low monthly cost and protection for critical medical events. Just know that routine medical care will primarily be out-of-pocket.
The second most affordable plan offered.
Key features of the ACA Silver plan include:
- Moderate monthly premiums
- Moderate costs when care is required
- Deductibles are lower than the Bronze plan
- Insurance carrier pays 70%, and you pay 30%
- Many qualify for extra savings, called cost-sharing reductions
Bottom line – the Silver plan often makes sense if you qualify for the cost-sharing reductions that are specific to the Silver plan. Thousands of dollars are usually saved on a yearly basis through the reductions.
The second most expensive plan offered.
Key features of the ACA Gold plan include:
- High monthly premiums
- Low costs when care is required
- Deductibles are typically low
- Insurance carrier pays 80%, and you pay 20%
Bottom line – the Gold plan is typically ideal for someone who requires medical care often. You will pay more each month, but the majority of your costs are covered when you do receive treatment.
The most expensive plan offered.
Key features of the ACA Platinum plan include:
- Highest monthly premiums
- Lowest costs when care is required
- Deductibles are the lowest
- Insurance carrier pays 90%, and you pay 10%
Bottom line – the Platinum plan is an excellent fit for someone who requires a lot of medical care and has the budget for high monthly premiums. Despite the costly premiums, you may end up saving money if significant medical care is required.
It is important to know that you have the ability to save on your premiums with all four plan options. Your income determines whether you qualify for savings, and is calculated during the application process.
Frequently Asked Questions About The ACA
Here, you will find frequently asked questions about the Affordable Care Act, or Obamacare, and their answers.
What do I need to buy an ACA health insurance plan?
Think of the following as a checklist of items you should have on hand before applying for coverage.
- Your information – legal name, date of birth, and other basic information.
- Household information – spouse or partner, children, other dependents.
- Address – your residence affects the type of coverage available to you.
- Others’ information – anyone else applying for coverage will share their basic information.
- Social Security numbers – for everyone on the application.
- Immigration information – if applicable, including documentation.
- Tax information – if you file federal tax returns, whether you file separately or jointly, and whether you claim dependents.
- Employer and income information – wages, tips, pay stubs, unemployment compensation, Social Security payments, alimony, retirement or pension income, investment income, rental income, or other sources of taxable income.
- Current health insurance information – if you are currently enrolled in a health plan, such as Medicaid, Tricare, VA health care, Peace Corps, Children’s Health Insurance Program, etc.
- Employer information – for each person in your household, information on any job-based health plan someone is eligible for.
- Health Reimbursement Arrangement (HRA) – whether someone in your household is offered an HRA through their employer.
By preparing all necessary information ahead of time, the process for securing an ACA plan will go smoothly.
Should I use a broker?
A health insurance broker will work alongside you to compare and contrast policies, while tailoring options to fit your specific needs.
A broker’s expertise on the intricacies of the Affordable Care Act, and its ever-evolving features, is priceless for someone needing healthcare coverage.
You should know that you do not pay a broker. They receive compensation from the health insurance carrier.
Can I buy ACA coverage through the Marketplace instead of using Medicare?
In fact, it is illegal for someone to sell you a Marketplace plan if they know you have Medicare.
And, it is against the law to have both Medicare and a Marketplace plan.
There are, however, a small number of circumstances in which you can opt for a plan through the Marketplace instead of Medicare:
- If you are paying a premium for Part A.
- You are eligible for Medicare, but have not enrolled in the program – because you would have to pay a premium, you have a medical condition (like end-stage renal disease) and have not enrolled into Medicare yet, or you are not collecting Social Security benefits before you are eligible for Medicare.
Work with a broker to confirm whether you can select a plan through the ACA instead of Medicare.
What determines how much I pay for a health insurance plan?
Your household’s expected income, along with the number of dependents, determines whether you qualify for savings. Most families do qualify for subsidies or premium tax credits.
Further, there are three primary components to your healthcare costs: premiums, deductibles, and out-of-pocket fees:
- Premiums – the amount you pay on a monthly basis for your healthcare coverage.
- Deductibles – money you are required to pay for medical services before your insurance carrier pays.
- Out-of-pocket fees – on a yearly basis, the maximum amount of money you pay for covered medical services.
Who should buy health insurance through the Marketplace?
The Marketplace is designed for anyone who does not have health insurance coverage elsewhere.
If you have a health plan through your employer, you can still buy coverage, but you will be required to pay full-price, unless your employer’s health plan does not meet certain requirements (most employer-provided plans do).
Further, if you do not already have Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or another source of health coverage, finding a plan through the exchange makes sense.
There are five important steps you need to take to enroll in a Marketplace plan through the Affordable Care Act.
First, be sure to partner with a broker. That way, you can feel confident that someone is working on your behalf to sort through the many plans and features of the exchange to find the best health insurance option for your needs.
Second, have all pertinent information on hand to be ready to apply. Mark your calendar for the Open Enrollment Period (OEP): November 1 – January 15 (in most states).
Or, with the help of a broker, determine if you qualify for a Special Enrollment Period (SEP).
Third, submit your application and receive results right away. You will see a breakdown of your monthly premiums, savings and tax credits, if you qualify.
Fourth, enroll in the health coverage plan that best fits your needs. You will pay your premium to the health insurance carrier for coverage to begin.
Fifth, reevaluate your plan every year. Has your needs, budget, or health changed? Be ready to adjust your plan if necessary.